Could Measles Be the Next Big Outbreak?
Pediatric vaccinations are down since the start of the pandemic. Here’s why that has experts concerned.
Amanda*, 27, scheduled a routine vaccine appointment for her one-year-old in March 2020, the week after her husband’s planned spring break from work. The last thing she expected was that in that same month, the world would be upended when COVID-19 was declared a global pandemic. In the early scramble of lockdown, Amanda called her pediatrician to reschedule her child’s vaccines for a later date. “Then more months went by,” she recalls, and she just kept putting it off.
Now, a year later, Amanda knows it’s time to get that appointment on the calendar. “He’s already had all his basic stuff: three rounds of Tdap (tetanus, diphtheria, and pertussis) and his MMR (measles, mumps, and rubella), so we’ve checked the major boxes,” she says. “I knew this other stuff—his fourth dose of Tdap and the Hib (Haemophilus influenzae type b) shot—was a little more flexible.” It didn’t feel worth it to expose her toddler to COVID, especially while he was too young to wear a mask. “We have so little exposure at home, so the doctor’s office scares me more than the zero exposure he is getting right now.”
Amanda’s worries illustrate a crucial tension parents have been feeling this year: What’s the line between minimizing COVID exposure and being proactive about your child’s other health needs? “We have not seen a period of time where vaccines dropped across the board as they have in this last year,” says Sean O’Leary, M.D., professor of pediatrics at the University of Colorado Denver Anschutz Medical Campus in Aurora. Holding off on these shots could come at a cost, especially for children with compromised immune systems. O’Leary and other experts are sounding the alarm about low pediatric vaccination rates in the U.S., which could leave children susceptible to other infectious diseases like measles, pertussis, or polio.
What the Numbers Show
Early in the COVID-19 pandemic, immunization rates in children saw a swift and precipitous decline. A CDC analysis reported a decrease in more than 2.5 million orders of non-influenza childhood vaccines in March and April 2020 (as compared to the numbers reported the previous year).
This news immediately had pediatricians concerned. “When the pandemic hit, everything really shut down,” O’Leary recalls. “Nobody was even leaving their house, and that resulted in people not going in for their check-ups.” In June 2020, CDC director Robert Redfield penned a public letter advocating for a concerted effort to get childhood vaccines back on track. But that didn’t fix the problem overnight; in September, the Centers for Medicare & Medicaid Services (CMS) reported a 22% decrease over the summer in vaccinations for children under two years old.
Rates have improved since those initial months of lockdown, says L.J Tan, chief strategy officer for the Immunization Action Coalition (IAC) in Saint Paul, MN. But they are not yet back to where they should be to make up for the initial drop. “If you look at claims data, you can see how many healthcare providers are seeking payment for pediatric vaccinations,” Tan explains. “Those rates remain significantly lower from what they were before COVID … anywhere from 11 to 20%.”
Drug manufacturers like Sanofi Pasteur are tracking similar trends in their data. “We’re able to see by virtue of the volume of product that we distribute,” says Julian Ritchey, U.S. head of vaccine public affairs and advocacy at Sanofi Pasteur in Bridgewater, NJ. “We did see a significant change last year with the advent of COVID, where everything just fell through the floor.” And while those rates have improved month by month, there hasn’t been the massive uptick that experts might hope for. “The real source of concern is that the volume of return has not completely compensated for the gap that occurred,” Ritchey says. “As a result, there is still a huge number of under-immunized people.”
The Reason for Those Missed Visits
During the initial months of COVID quarantine, most people with the ability to stay home were doing so—and that meant cancelling travel, social plans, and to-do list items like doctors’ appointments. “Parents would say, ‘I don’t want to expose my kids to COVID-19,’ so they just didn’t show up for primary care visits,” Tan recalls. Then, for whatever reason—be it ongoing pandemic concerns or unintended forgetfulness—they never made a new appointment.
For parents with chronic illness in the family, this can truly feel like a life-or-death decision. Natalie Hayden, 37, is a mother of two who has been living with Crohn’s disease since 2005. In April 2020, she had to decide whether to bring her daughter in for her 15-month vaccination appointment. “When COVID struck, it was very concerning for the community of immunocompromised people like myself,” Hayden recalls. She didn’t want to set her children back, but at the same time, she worried about potential exposure to COVID in a doctor’s office setting.
Hayden wrote to her pediatrician through the office’s online portal, explaining her situation and asking for advice. Luckily, her doctor offered a solution. “What we came up with was to hold off on the 15-month well visit and reschedule that at 18 months,” Hayden says. “So, my daughter received her varicella and hepatitis B vaccines at the 18-month appointment.” By that point, it was mid-summer, and Hayden felt more comfortable with limited, socially distanced in-person appointments. “I started doing more appointments for myself in person, and that laid the groundwork for bringing my kids in,” she says. “I was seeing all those safety protocols in place and then thinking, ‘Okay, I can do this.’”
Like Hayden’s pediatrician, many doctors are trying to encourage patients to feel safe coming into the clinic. In May 2020, the American Academy of Pediatrics launched its #CallYourPediatrician campaign to build trust in the safety of doctor’s visits. Still, it’s hard to counter the prevailing societal fear of COVID-19. Late last year, O’Leary and his team at the University of Colorado Denver Anschutz Medical Campus partnered with the CDC to survey pediatricians and primary care providers about what it has been like to vaccinate kids during the pandemic. Most doctors reported that they stayed open for vaccinations throughout the duration of the COVID crisis, but it wasn’t exactly business as usual. “The biggest barrier [to providing vaccinations] was that patients or their parents were concerned about the risk of getting COVID-19,” O’Leary says. “Another factor they identified was fewer in-person visits for things like sports—there are not as many kids doing sports, so they’re not coming in for their sports physicals.” Virtual learning has minimized the need for back-to-school visits and annual exams.
Why Vaccination Is So Important
To really understand the potential impact of this, it helps to have some context for why vaccination rates matter. “The reason why we don’t see outbreaks in infectious, vaccine-preventable diseases is that before COVID, we had really, really high immunization coverage rates in our pediatric population,” Tan explains. In 2017, the CDC reported that more than 90% of U.S. toddlers received all recommended vaccines, including polio, MMR, HepB, and varicella.
These high rates help ensure that outbreaks are extremely rare—so rare that when they happen, you probably hear about them on the news. “When we do see those outbreaks, the data is very clear that they are associated with pockets where immunization coverage rates dropped,” Tan says. “We call them pockets of resistance, where there is a community with a strong anti-vaccine foothold.” One example is the measles outbreak of 2019, where 1,282 cases of measles were confirmed in 31 states. More than 80% of these cases occurred in under-immunized communities such as the Orthodox Jewish population in New York.
Tan warns that outbreaks like this could happen again—and on a much larger scale—if vaccination rates don’t improve in 2021. “I’m not saying the sky is falling, but these are things we are watching out for,” he says. “We will get those pockets where we drop below herd immunity, and then all you need is one person to come in with measles and it’s going to explode. That’s what we’re worried about.”
The good news is that social distancing has decreased the likelihood of transmission for many infectious diseases. “Right now, we’re still practicing a lot of measures to control the spread of infectious diseases,” O’Leary says, “fewer kids in school, people wearing masks, physical distancing, not having large crowds, and quite a bit less domestic and international travel.” But there’s hope that we might be over the worst of this pandemic in the U.S., which ideally means a return to normal as soon as later this year. “The concern is that as things open back up … if we don’t catch up a lot of these people who are behind on their vaccines, we may be in for real trouble from other vaccine-preventable diseases that can spread even faster than COVID-19,” O’Leary cautions. “The ones we’d be thinking of are measles, pertussis, or even diseases we haven’t seen in the U.S. in decades, like diphtheria or polio.” The likelihood of an outbreak isn’t totally clear (we’re in uncharted territory with this pandemic), but experts agree that it’s better to address this proactively rather than waiting to find out.
The Campaign to Get Kids Immunized
It will take a village to get vaccination rates back where they should be, and that means everyone—healthcare providers, state and local governments, and the public—has a role to play. “We need to reassure all our public that it is safe to go and get their preventive visits, which would include catching up on their immunizations,” Tan says. Back-to-school presents the perfect time to do this, as children go in for sports physicals or other routine check-ups to prepare for the academic year.
The CDC is already taking steps to make this happen. The agency released an open letter on March 21, encouraging providers and the public to get kids vaccinated before the start of the school year. The agency’s newest data showed a 14% drop in pediatric vaccine orders over the last year, and a full 20% drop in orders for the measles vaccine. “We’ve had school entry requirements before, and they are still there,” Tan notes. “If your kids are going to go back to school, they need to be immunized.”
It’s easy to forget about the potential for other diseases while COVID remains front-and-center in the news. But the reality is that things like measles can be even more serious in children. “COVID-19 is obviously a severe disease,” O’Leary says. “But a lot of the diseases that we’re vaccinating our children for are much more severe in children than COVID-19.” He urges parents to reach out to their child’s pediatrician to ask for guidance on vaccinations. You can also use that time to inquire about COVID safety measures in the doctor’s office, to help with your peace of mind.
Don’t be too hard on yourself if you fell behind on your kids’ vaccines (you’re not alone!), but also know that now is the time to get them caught up if you haven’t already. “It’s not just about COVID-19 vaccination,” Tan says. “It’s about all the other vaccines that have to happen at the same time.” As we enter this new and hopefully brighter spring and summer, the best thing you can do for your child—and for public health—is to get back on track with those annual visits to your pediatrician.
* Name has been changed.
Vaccination Rates: Centers for Disease Control and Prevention. (2020.) “Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020.” cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm?s_cid=mm6919e2_w
June 2020 Open Letter: Centers for Disease Control and Prevention. (2020.) “HHS Call to Action Letter-COVID-19.” cdc.gov/vaccines/partners/downloads/call-to-action-508.pdf
CMS Rates: U.S. Centers for Medicare & Medicaid Services. (2020.) “Fact Sheet: Service Use among Medicaid & CHIP Beneficiaries age 18 and Under during COVID-19.” cms.gov/newsroom/fact-sheets/fact-sheet-service-use-among-medicaid-chip-beneficiaries-age-18-and-under-during-covid-19
CDC Pediatrician Survey: Centers for Disease Control and Prevention. (2020.) “US Primary Care Providers’ Experiences and Practices Related to Routine Pediatric Vaccination During the COVID-19 Pandemic.” cdc.gov/vaccines/hcp/pediatric-practices-during-COVID-19.html
2017 Vaccination Coverage: Centers for Disease Control and Prevention. (2018.) “Vaccination Coverage Among Children Aged 19–35 Months — United States, 2017.” cdc.gov/mmwr/volumes/67/wr/mm6740a4.htm
Measles Outbreak 2019: Centers for Disease Control and Prevention. (n.d.) “Measles Cases and Outbreaks.” cdc.gov/measles/cases-outbreaks.html
CDC Back-To-School Campaign: Centers for Disease Control and Prevention. (2020.) “Help Kids’ Safe Return to School - Get Caught Up on Recommended Vaccines.” cdc.gov/vaccines/hcp/clinical-resources/downloads/safe-return-school.pdf